Current through Register Vol. 46, No. 12, March 20, 2024
(a) Basic program
minimum coverage requirements. All program participating insurers issuing this plan
design must offer a basic policy/certificate providing minimum coverage under this
section. Additional products which exceed the basic policy/certificate minimum
coverage will be permitted. The insurer selling a policy/certificate providing
minimum coverage under this section must offer a policy/certificate providing the
basic 1.5/3/50 minimum plan design and the basic 2/2/100 minimum plan design under
sections
39.4 and
39.6
of this Part to the prospective insured at the same time.
(b) Minimum benefit standards for the 3/6/50 plan
design. To be approved as a qualified policy/certificate under this section a
policy/certificate shall provide coverage on an expense incurred, indemnity,
prepaid, or other basis and provide at least the following benefits:
(1) Nursing home care. Nursing home care coverage
shall be provided for not less than a lifetime maximum total of 36 months for each
covered person. A covered person must be permitted to substitute home care benefits
for nursing home care benefits on the basis of two home care days for one nursing
home day. Coverage of nursing home care shall consist of payment for skilled nursing
care, intermediate care, and custodial care in nursing homes of at least $ 387 per
day. Payment for nursing home care services may be limited to services rendered in a
nursing home licensed by the jurisdiction in which it is located. The minimum
nursing home daily benefit shall be increased each year on the first day of January
beginning in 2025. Policies/certificates sold after January 1, 2025 shall provide
benefits at the increased minimum standard in the year sold. Minimum daily benefits
for the next 10 years shall be as follows:
(i)
January 1, 2024 - $ 387 (nursing home), $ 193 (home care - 50 percent);
(ii) January 1, 2025 - $ 401 (nursing home), $ 200
(home care - 50 percent);
(iii) January
1, 2026 - $ 415 (nursing home), $ 207 (home care - 50 percent);
(iv) January 1, 2027 - $ 430 (nursing home), $ 215
(home care - 50 percent);
(v) January 1,
2028 - $ 445 (nursing home), $ 222 (home care - 50 percent);
(vi) January 1, 2029 - $ 461 (nursing home), $ 230
(home care - 50 percent);
(vii) January
1, 2030 - $ 477 (nursing home), $ 238 (home care - 50 percent);
(viii) January 1, 2031 - $ 494 (nursing home), $
247 (home care - 50 percent);
(ix)
January 1, 2032 - $ 511 (nursing home), $ 255 (home care - 50 percent);
(x) January 1, 2033 - $ 529 (nursing home), $ 264
(home care - 50 percent).
(2)
Home care. Home care coverage shall be provided when services are rendered in the
insured's place of residence, in a group setting such as an adult day care center,
or where human assistance is required by the insured to aid in necessary travel,
such as to a physician's office.
(i) Home care
benefits shall be provided for at least the following services: skilled nursing
care, home health care, personal care, assisted living and adult day care, provided
that such services are rendered by entities licensed and/or certified by the
Department of Health or agencies exempt from licensure or certification in
accordance with articles 28 and/or 36 of the Public Health Law and regulations
promulgated thereunder or section 505.14 of Part 505 of Title 18 NYCRR. Payment for
home care services received outside of New York State may be limited to services
rendered by an entity licensed to provide such services in the jurisdiction where
the services were rendered. It is also required that the insured has incurred
expense for the cost of a covered service.
(ii) For the purpose of special eligibility for
long-term care protection through the New York State Medicaid program under a
qualified policy/certificate, a covered person must be permitted to substitute home
care benefits for nursing home care benefits on the basis of two home care days for
one nursing home day. Complete substitution of home care benefits for nursing home
care benefits would result in a lifetime maximum total of 72 months of home care
benefits.
(iii) The minimum home care
coverage to be offered will be provided in an amount of at least 50 percent of the
current minimum nursing home care benefit as stated in this section. This minimum
home care coverage amount shall continue to be the minimum home care benefit
standard regardless of the amount of nursing home coverage actually
purchased.
(iv) Home care coverage which
exceeds the minimum benefit standards shall not affect the requirement for a
lifetime maximum total of 72 months of home care benefits. However, at the
discretion of the insurer, it shall be permissible to combine benefit days to pay an
amount in excess of the daily benefit amount set forth in the policy/certificate. In
no case where benefit days have been combined shall the equivalent of more than 31
days of home care benefits be provided in any one-month period.
(3) Nursing home care bed reservation (holds
nursing home bed when must leave the nursing home for a time period). The minimum
nursing home bed reservation coverage benefit shall be provided in an amount equal
to the nursing home daily benefit amount in effect under the policy/certificate for
at least 20 days annually.
(4) Respite
care. Respite care, meaning nursing home and/or home care services provided in lieu
of informal caregiver services, for at least 14 days coverage, shall be renewable
annually. Covered days of respite care need not be consecutive and shall be provided
at a daily amount equal to that provided for nursing home care under the policy or
certificate regardless of where the respite care services are actually rendered and
regardless of the actual cost of such services. Payment for respite care services
may be conditioned upon the following:
(i) a
covered person's eligibility to receive policy/certificate benefits for a period not
to exceed six consecutive months without regard to receipt of formal nursing home
and/or home care services and without regard to satisfaction of policy/certificate
waiting periods;
(ii) expenses for
respite services qualifying under the policy/certificate are incurred;
(iii) once the requirement of subparagraph (i) of
this paragraph has been met an insurer may not impose another such requirement
unless the covered person is no longer eligible to receive policy/certificate
benefits; or the policy/certificate is lapsed or cancelled; or benefits under the
policy/certificate are exhausted.
(5) Hospice care. The minimum hospice care
coverage benefit shall be provided in an amount equal to the nursing home daily
benefit in effect under the policy/certificate in an inpatient setting and at the
home care daily benefit in effect under the policy/certificate in all other
settings.
(6) Alternate care. Where an
otherwise covered person is unable to obtain access to nursing home care or home
care services, and the covered person is in a hospital setting awaiting the
availability of such services, and has been determined by the attending physician to
be in alternate care status, such covered person shall, for the purpose of benefit
eligibility including the satisfaction of any elimination period, be deemed to be
receiving the nursing home care or home care services for which such covered person
is awaiting placement. Benefit payments while the covered person is in alternate
care status shall be the nursing home daily benefit in effect under the
policy/certificate.
(7) Care management.
The minimum care management coverage benefit shall be provided in an amount equal to
the nursing home daily benefit in effect under the policy/certificate for at least
two days per year.
(8) Inflation
protection. Qualified policies/certificates shall provide lifetime inflation
protection of three and one-half percent compounded or five percent compounded on an
annual calendar or policy year basis. The insurer shall permit the covered person to
choose either the three and one-half percent compounded or the five percent
compounded lifetime inflation option. Inflation protection shall be mandatory except
if the policy/certificate is purchased at or after age 80.
(9) Level premium. Step rate premiums,
policy/certificate options to increase benefits, or any premium payment feature
where the premium rate rises automatically after issuance shall not be permitted.
Premiums for qualifying policies/certificates shall be level for the duration of the
policy/certificate except where a rate increase is granted by the Superintendent of
Financial Services for all persons covered by a specific policy/certificate
form.
(10) Replacement. If a long-term
care insurance policy/certificate qualified under this Part replaces another
qualified long-term care insurance policy/certificate under this Part, the replacing
insurer shall waive any time periods applicable to preexisting conditions, waiting
periods, and probationary periods in the new long-term care policy/certificate to
the extent such time has elapsed under the original policy/certificate. The insurer
may, however, exercise any legal rights available with regard to alleged fraud or
material misrepresentation in obtaining the replacement
policy/certificate.
(11)
Policy/certificate modification provision in the event of a national long-term care
program. Qualified policies/certificates shall include a provision for modification
of such policies/certificates in the event of enactment of a national long-term care
program using public funds which program duplicates coverage provided under
qualified policies/certificates. The modification provision must state that the
policy/certificate will be amended to the extent possible to provide benefits
appropriately interrelated with the national program. In the event of modification
or, if necessary, termination the insurer must submit a plan to the superintendent
providing for any premium adjustment or refund required as a result of modification
or termination.
(12) Elimination
periods. Elimination periods no greater than 100 days are permitted in qualified
policies/certificates. Only a single elimination period for all covered services
will be permitted. The commencement of a new elimination period is permitted only
when a period of care is separated from another period of care by more than six
months.
(13) A long term care
policy/certificate providing coverage under this section on an indemnity, prepaid,
or any basis other than expense incurred may be sold in this State. However, the
insurer selling such a policy or certificate must offer a policy/certificate
providing coverage on an expense incurred basis at the same time to the prospective
insured.